Every finding on record at Capital Homecare LP

Purpose of visit: Recertification survey Entrance Date: 06/28/2021 at 11:05 AM with the Administrator/DON, Employee A. Agency Census: 171 Licensed and Certified Home Health - 171 Licensed Home Health - 0 Personal Assistance Services - 0 Exit Date: 07/01/2021 at 3:44 PM with the Administrator/DON and the Vice President of Home Health, Employee B. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. The agency was in compliance with the Conditions of Participation for Emergency Preparedness. Abbreviations: DON - Director of Nurses

Purpose of visit: Recertification survey Entrance Date: 06/28/2021 at 11:05 AM with the Administrator/DON, Employee A. Agency Census: 171 Licensed and Certified Home Health - 171 Licensed Home Health - 0 Personal Assistance Services - 0 Exit Date: 07/01/2021 at 3:44 PM with the Administrator/DON and the Vice President of Home Health, Employee B. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations: DON- Director of Nurses

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to provide 5 of 5 patients, whose home folders were available for review during home visits, with the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that served the area the 5 patients resided in: Agency on Aging Center for Independent Living Protection and Advocacy Agency, Aging and Disability Resource Center; and Quality Improvement Organization. This failure prevented the agency patients from accessing and obtaining community services that were not provided by the agency. Findings: On 06/28/2021 the surveyor requested and reviewed the sample admission packet for the agency provided by the Administrator/DON, Employee A. Review of all the documents in the sample admission packet on 06/28/2021 at 1:30 PM revealed no names, addresses and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. Review of the clinical record on 06/28/2021 for Patient 1 revealed a start of care date of 05/28/2021 with a primary diagnosis of Aphasia Following Cerebral Infarction. During a home visit with Patient 1 on 06/29/2021 at 10:15 AM, the surveyor reviewed the home folder provided by the agency to Patient 1. The agency provided home folder did not include the names, addresses, and telephone numbers of the Federally-funded and state-funded entities described above. The surveyor asked Patient 1's family member, Identifier AA if the agency had provided any other paperwork that was not in the home folder. Identifier AA stated all the paperwork provided was in the home folder. Review of the clinical record on 06/28/2021 for Patient 2 revealed a start of care date of 06/24/2021 with a primary diagnosis of Aftercare Following Joint Replacement Surgery. During a home visit with Patient 2 on 06/29/2021 at 2 PM, the surveyor reviewed the home folder provided by the agency to Patient 2. The agency provided home folder did not include the names, addresses, and telephone numbers of the Federally-funded and state-funded entities described above. The surveyor asked Patient 2 if the agency had provided any other paperwork that was not in the home folder. The family member stated no paperwork had been removed from the home folder. Review of the clinical record on 06/28/2021 for Patient 3 revealed a start of care date of 05/07/2021 with a primary diagnosis of Hypertensive Heart Disease with Heart Failure. Review of the clinical record on 06/28/2021 for Patient 4 revealed a start of care date of 05/07/2021 with a primary diagnosis of Unspecified Dementia without Behavioral Disturbance. During a home visit with Patient 3 and Patient 4 on 06/29/2021 at 3 PM, the surveyor reviewed the home folders for both patients provided by the agency. The agency provided home folders did not include the names, addresses, and telephone numbers of the Federally-funded and state-funded entities described above. The surveyor asked Patient 3 if the agency had provided any other paperwork that was not in the home folders. Patient 3 stated he did not believe any paperwork had been removed from the home folders. Review of the clinical record on 06/30/2021 for Patient 5 revealed a start of care date of 06/18/2021 with a primary diagnosis of Pain Due to Internal Orthopedic Prosthetic Device or Graft. During a home visit with Patient 5 on 06/30/2021 at noon, the surveyor reviewed the home folder provided by the agency to Patient 5. The agency provided home folder did not include the names, addresses, and telephone numbers of the Federally-funded and state-funded entities described above. The surveyor asked Patient 5 if the agency had provided any other paperwork that was not in the home folder. Patient 5 stated all the paperwork provided by the agency was in the home folder. An interview was conducted with the Administrator/DON on 07/01/2021 at 1:45 PM. The surveyor reviewed the findings of the clinical record reviews and home visit findings. The surveyor asked why the agency had not provided the names, addresses, and telephone numbers of the Federally-funded and state-funded entities that served the areas the 5 patients resided in. The Administrator / DON stated she wasn't sure what information the surveyor was referring to. The surveyor reviewed the sample home folder provided by the agency that included a list of the required entities whose names, addresses and telephone numbers were blank. The surveyor explained this was the same findings in the review of the home folders during home visits. The Administrator/DON stated the nurses were not filing the information in during admission visits. The Administrator/DON showed the surveyor the information was completed in the electronic medical record admission paperwork. The surveyor asked how the information was provided to the patients. The Administrator stated: "It isn't." The surveyor requested the client rights policy and procedures for the agency. The surveyor reviewed the policies and procedures provided by the agency and failed to find a policy and procedure that addressed the client right to be advised of the names, addresses, and telephone numbers for the Agency on Aging, Center for Independent Living Protection, and Advocacy Agency, Aging and Disability Resource Center; and Quality Improvement Organization. No additional information was provided to explain or correct the findings.